Senior Clinical

Case Study
DHY 406: Principles of
Dental Hygiene Practice III
Gabrielle Gasca, DHS
Component 1:
Assessment
 Patient Information
Pt Name:
Sex: Male
Age: 33 Chief Concern: pt reports has not
been to the dentist in over 5
Race: Hispanic
years (pt overdue for dental
exam and therapy)
Owns his own painting and pressure
washing business- busy season begins Pt also reports interest in
spring through the summer whitening after treatment

Vapes daily as well as recreationally

uses marijuana, social drinker, practices
daily meditation and yoga
 Health History
ASA: II (smoking status- daily vape, marijuana use; social drinker)
Vital Signs:
● 1/27/2023 ● 3/3/2023
○ BP: 127/77 mmHg (elevated) ○ BP: 118/73 mmHg (healthy)
○ P: 48 ○ P: 55
● 2/6/2023 ● 3/15/2023
○ BP: 116/77 mmHg (healthy)
○ BP: 115/81 mmHg (HBP stage 1)
○ P: 63
○ P: 65
● 2/22/2023
○ BP: 130/84 mmHg (HBP stage 1)
○ P: 72
Physical characteristics: about 5’11 & 180lbs
Medical History: no treatment modifications, pt prefers to listen to music during
treatment (does not like sound of scalers and ultrasonic)
Pharmacologic History: pt reports taking no medications
Medical and Dental Indications
Findings: Incipient decay, palatal stomatitis, smoking habits, severe gingival inflammation,
periodontitis, attachment loss, moderate to high caries risk, poor oral health, elevated-HBP stage 1

Pt reports gap in dental care, been about 5 years since last dental visit. CRA
completed, mod-high caries risk. Pt uses a vape daily and uses marijuana
recreationally–Pt presents with palatal stomatitis.

Pt has never had a “deeper cleaning”, however, knew that because it had been
so long he would need more than a “regular cleaning”.

No medical indications that prevent treatment, advised pt to see PCP for

swollen left tonsil and potential hypertension.
Privacy and HIPAA
Patient Privacy and HIPAA compliance was
maintained by not using patient name and having
verbal consent for all photos as well as permission
from patient for information collected to be used for
learning aspects (case study project)

Other privacy and HIPAA consent per Neighborcare

Health was also signed and obtained prior to any
treatment in the DEC

Removed patient name and signature from all

documents to be used in case study project
 Dental History & Risk Assessment
Patient has not had consistent dental care
(gap in care) last visit about 5 years ago
● Overbite: slight (normal)
● Overjet: 3mm
● Occlusion R/L Molar: Class III
● Occlusion R/L Canine: Class I
● Spacing: slight crowding
● Crossbite: #10, 11 / #22
● Radiographic Findings: calculus, bone
loss, radiolucency, incipient decay
● Occlusal Wear: localized moderate
Caries Risk Assessment: Mod-High
● Visible plaque
● Plaque Index
○ Gen mod interproximal and along
gingival margins
● Daily vape use w/ flavoring
● Exposed root surfaces
● Marginal discrepancies
 EO/IO
Extra Oral Exam:
● Enlarged left submandibular lymph node
○ Pt unaware, asymptomatic
○ Pt reports no seasonal allergies
● Slight deviation to the left upon opening

Intra Oral Exam:

● Enlarged left tonsil
○ Pt unaware, asymptomatic
○ DDS advised pt to get evaluate by PCP (as abnormal)
● Bilateral linea alba
● Fordyce granules on left buccal mucosa
● Left buccal mucosa cheek bite
● Slight bilateral scalloped tongue w/ moderate coating
● Palatal stomatitis (slight)
○ Pt reports daily use of vape pen
○ Pt reports recreational marijuana use
 Gingival Description
LR- Gen Unhealthy- gen red color w/ cyanotic color at S5 B/L, loc severe
bulbous S5, gen mod rolling, gen mod soft w/ severe edematous, gen smooth
texture, gen 1-3mm recession

UR- Gen Unhealthy- gen darker pink to red in color w/ cyanotic margins at S2,
gen mod bulbous papilla, gen mod rolling, gen soft and spongy tissue w/
edematous on facial aspects, smooth texture, gen 1-3mm recession

UL- Gen Unhealthy- gen dark pink to red in color w/ cyanotic margins at S2, gen
mod bulbous papilla, gen mod rolling, gen soft and spongy tissue w/ edematous
on facial aspects, smooth texture, gen 1-3mm recession

LL- Gen Unhealthy- gen red color w/ cyanotic margins at S5, gen mod to severe
bulbous papilla, gen mod rolling, gen soft and spongy tissue w/ edematous on
facial aspects, smooth and shiny texture, gen 1-3mm recession
Pre-Treatment Photos
Current Dental Conditions

Missing #17 & #32

Incipient caries #5D, #14M, #21D
Periapical abscess #24
RCT retreatment #24 w/ crown
Existing Conditions: composites #14OL, #18B, #31B (in
good condition)
 Radiographic Findings
Radiographic calculus
Bone loss
Radiolucency apex #24
Root resorption #20 as well as premolars
● originally thought root resorption on premolars, after DDS exam
says that just may be pts anatomy due to all the premolars
having short roots (better able to see in pano)
 Prelim AAP:
1999 III/2/D3
2017 IIB

Perio: gen 4-6mm

pocket depths, gen
heavy bleeding
upon probing w/ loc
7mm #2, #15, #30
& #31 on the
lingual aspects
 Perio
Examination
Occlusion: Molar Class III R & L
Spacing: Crowding
Crossbite: #10,11/22
Marginal ridge discrepancies:
generalized
Occlusal wear: moderate and localized
Mobility: none
Open/Loose contacts: none
Super-eruption: none
Buccalverted: #22
Lingualverted: #10
Mesially rotated: #6, 8,9 11, 24, 25
Distally rotated: #26
Furcations: Class I #2MD, 3MD, 14MD,
15MD, 18B, 19B, 30B, 31B
 Psychosocial Observations & Current
Self-Care Routine
Current Self care:
● Pt brushes 1x/day (morning)
● Does not floss
● Used fluoride toothpaste

Patient is motivated about improving and maintaining oral health. Unaware that bleeding
while brushing indicted disease. Patient vapes daily along with recreational marijuana use
and is open to cessation but needs to wean off at his own pace.

Patient asked questions on best products to use and was excited to share he purchased floss
picks to start using at least 3-4x/week. Discussed proper toothbrush (modified bass) and
flossing (c-shape_ technique for plaque removal.
 Referral Needs
Endodontist for retreatment of #24

● Radiolucency at previous endo treatment

● Pt reports endo was completed in 2012
● Pt reports asymptomatic
● Pt deferred, will let us know when ready
● Monitor for now
Component 2:
Diagnosis &
Planning
 Dental
Hygiene
Diagnosis
 Dental
Hygiene
Care Plan
 Treatment Plan &
Rationale
Treatment Goals/Desired Outcomes:
● Reduced pocket depth and gingival bleeding
Therapeutic Strategy:
● Treatment broken up into 4 appointments
● NSPT
● D4341 (4+ teeth per quad) w/ LA
Prevention Education Strategy:
● Relationship of biofilm and PD (introduce proper TB
technique)
● Importance of IP cleaning (flossing technique w/ std
floss and other aids)
● Arestin placement and its benefit in conjuncture to
NSPT
● Relationship of smoking and PD (delayed healing,
bone loss) also discuss smoking cessation
● Tissue Reeval- recheck pocket depths and bone
levels
● PM recall (advise pt to keep up with recall appts)
 Component 3:
Implementation
 Treatment Provided and Treatment
Revisions
● 1/27/23 Initial Assessment Appointment
○ FMX and Pano
○ FMPC
○ TC/Occlusion
○ DDS exam
● 2/6/23 LR NSPT with LA and Arestin Placement #31ML 7mm pocket
● 2/22/23 UR NSPT with LA
● 3/3/23 UL NSPT with LA
● 3/15/23 LL NSPT with LA and LR Tissue Re-Eval
● TxN: 3 month Perio Maintenance (June 2023)

After each appointment advised pt on numbness, if sore can take OTC analgesic, warm salt water rinse
to help with healing, advised complete of treatment

Arestin placement- educated pt on antibiotic use in conjunction with NSPT, advised patient not to eat
crunchy or sticky foods for one week; no interdental cleaning in areas for 10 days. Gave pt educational
materials to take home.
1/27/23 Initial Assessment Appointment
● FMX and Pano
● FMPC
● TC/Occlusion
● DDS exam
2/6/23 LR NSPT with LA and Arestin Placement #31ML 7mm pocket

● Treatment went as planned, only revision was hematoma education

● Hematoma formation
○ Avised pt to ice area and be aware of potential further bruising in area
2/22/23 UR NSPT with LA

● Treatment went as planned, no revisions

3/3/23 UL NSPT with LA

● Treatment went as planned, no revisions

3/3/23 UL NSPT with LA
● Treatment went as planned, no revisions
● Pt refused FlV
 Patient Care & Self Care
Patient Care:
Starting with the LR allowed patient to
be able to feel and see the difference
in therapy provided.
Patient become more motivated to
complete periodontal therapy.
Patient asked questions about
condition and if this type of therapy
was typical with the amount of
appointments.
Patient is more motivated and
noticing a decrease in bleeding when
brushing/flossing and less
inflammation.
No pain or sensitivity reported
Self Care:
Patients progress with preventative
education plan is good.
Educated pt on proper brushing and
flossing technique (std string).
Pt wanted other options due to not
liking string floss, discussed picks as
well as water flosser.
Pt appreciated TB help as he is
noticing less plaque and bleeding.
Vaping is a contributor to periodontal
disease, however pt is not ready to
give this up fully at this time.
Component 4:
Evaluation
 Before &
After
Treatment
Photos
 Post Treatment Evaluation
CC: pt interested in whitening
HHx Update: pt reports no medications or changes at this time; daily vape use
EO: no changes
IO: cheek bite healed, hematoma healed
Post Treatment Perio Exam: see next slide (tissue re-eval and GD), gen
reduction in pocket depth, 7mm pocket still present, less inflammation
Oral Homecare Outcomes: pt understands the importance of good HC, brushing
technique has improved, less bleeding present, began flossing about
3x/week-pt reports still trying to create the habit
Discussion Points w/ Patient: importance of routine professional care (PM
recalls) to maintain periodontal status (no further tissue loss), importance of
proper homecare–explained patient responsibility in fighting disease
Future Recommendations: Continue to monitor radiolucency apex #24 and
incipient decay #5D, #14D, #21D. Recommend return every 3-4 months for perio
maintenance appointments
 Post Treatment Perio Exam
Tissue Re-Eval Quad 4
GD- LR (2/6/2023)
Gen Unhealthy- gen red color w/ cyanotic
color at S5 B/L, loc severe bulbous S5, gen
mod rolling, gen mod soft w/ severe
edematous, gen smooth texture, gen 1-3mm
recession
GD- LR (3/15/2023)
Gen pink color w/ dark pink margins, loc mod
bulbous papilla S5, gen slight rolling, loc soft
and spongy anterior papilla, gen smooth w/
slight stippling, gen 1-3mm recession
What was learned from treating the case?
I was able to see this patient from start to finish (Initial Assessment and all 4 NSPT appointments). I
was lucky this patient was a friend and happy to help me in my learning in terms of competencies and
injections. Being a friend, he was also not afraid to let me know if something was not feeling good
during the appointment or what worked well for him. This was great to hear as I am always trying to
improve with patient comfort and care.

It was exciting to see the progress achieved over a couple months that I had yet to see with any other
patient as we do not always see the same patients. Seeing the therapy work before my eyes made me
feel like I am helping patients and everything I have learned in action.

For smoking cessation although he was not quite ready to quit, I was able to educate how this has a
negative effect on his oral health and the benefits to quitting. Maybe sometime in the future.

Arestin was another thing I was able to complete and explain the benefits in combination with his NSPT
appointment.

This case study was able to provide me with confidence in working with a complicated case and help
me with my instrumentation in removing heavy tenacious calculus. I was able able to create a safe
place for my patient (HIPAA) and build good rapport.
 Which modifications would enhance
treatment outcomes?
Due to the patients stage and grade of periodontal disease (IIB), smoking cessation would enhance
treatment outcomes. As we have learned, smoking is a risk factor in periodontitis, oral cancers and
much more. Had the patient been more interested in hearing about cessation or more positively ready
to change their habits treatment would have been more beneficial.

Another modification would have been if the patient purchased an electric toothbrush. I know these
can be expensive but having a power toothbrush that can do most of the work for you (assuming you
have the right technique) is extremely beneficial in removing plaque biofilm.

Lasly, daily flossing would have created better outcomes. When doing the tissue re-eval, there was
already a lot of build up on the lower anteriors. Daily flossing and help debride much of interproximal
biofilm that can later (if not remove) become hardened calculus.
References:
About Arestin. ARESTIN. (n.d.). https://www.arestin.com/about-arestin/

Alexandridi, F. Tsantila, S., Pepelassi, E. Smoking Cessation and Response to Periodontal Treatment. Australian Dental Association.
(2018). 63(2):140-149. Doi: 10.1111/adj.12568

Machado, V., Aguilera, E. M., Botelho, J., et al. Association between Periodontitis and High Blood Pressure: Results from the Study of
Periodontal Health in Almada-Seixal. Journal of Clinical Medicine. (2020). 23;9(5):1585. Doi:10.3390/jcm9051585